Norvax University Online Training: Medicare 101: Introduction to Medicare

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Agenda

• Medicare Eligibility & Enrollment

• Overview of Medicare Coverage Options

• Benefits & Cost of Original Medicare

• Medicaid

• Medicare Resources for

More Information

What is Medicare?

• Medicare is a federal program which provides

health insurance benefits for people who meet

one of 3 categories:

– 65 or Older

– Those with End Stage Renal Disease (ESRD)

– Those under 65 with certain disabilities

• Administration

– Centers for Medicare & Medicaid Services (CMS)

– CMS is an agency within the Department of

Health and Human Services (HHS)

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What is Medicare?

• The Social Security Act established both the

Medicare and Medicaid programs in 1965.

• Original Medicare is a “fee-for-service” system,

where a Medicare beneficiary is charged a fee for

each health care service/supply received.

• Beneficiaries can see any provider that is approved by

the Medicare program.

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Four Parts of Medicare

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Part A Hospital

Insurance

Part B Medical

Insurance

Part C Medicare

Advantage

Part D Medicare

Prescription Drug

Coverage

Enrollment

• Automatic for those receiving

– Social Security benefits

– Railroad Retirement Board benefits

• Initial Enrollment Period Package

– Mailed 3 months before

• 25th month of disability benefits

• Age 65

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Enrolling in Medicare

• Some people need to sign up

– Those not automatically enrolled

• Enroll through Social Security

– Railroad Retirement Board for

railroad retirees

• Apply 3 months before age 65

– Do not have to be retired

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Enrollment Periods

• Initial Enrollment Period (IEP)

– Begins 3 months prior to the month of turning age 65 and continues

through the end of the third month after

• General Enrollment Period (GEP)

– Allows individuals who did not enroll in Part B during the IEP to enroll

between January 1 – March 31 of each year for a July 1 effective date

• Special Enrollment Period (SEP)

– Allows individuals who delayed enrolling in Part B because they were

receiving benefits through an employer as an active employee (or

dependent of someone who is); SEP runs eight months from the time of

retirement or loss of coverage

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Medicare Card

• Keep it and accept Medicare Parts A and B

• Return it and refuse Part B

– Follow instructions on back of card

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FRONT BACK

Medicare Options

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Overview of Medicare Options

• The choice of options to be considered are:

– Premium Cost

– Cost Sharing

– Network Providers

– Prescription Drug Coverage

– Value-Added Benefits

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Original Medicare

A&B

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Medicare Part A (Hospital Insurance)

Premium

• Most people receive Part A premium free

– If you paid FICA taxes for at least 10 years

• If you paid FICA taxes less than 10 years

– Can pay a premium to get Part A

– 30 or more quarters - $248/month in 2012

– Less than 30 quarters - $451/month in 2012

• May receive penalty if not bought when first eligible

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Medicare Part A Coverage • Inpatient Hospital Stays

– Semi-private room, meals, general nursing, and other hospital services

and supplies

– Care in critical access hospitals and inpatient rehabilitation facilities

– Inpatient mental health care in psychiatric hospital (lifetime 190-day

limit)

– Generally covers all drugs provided during an inpatient stay received

as part of treatment

• Skilled Nursing Facility Care

– Semi-private room, meals, skilled nursing and rehabilitation services,

and other services and supplies

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Medicare Part A Coverage • Home Health Care Services

– Can include part-time or intermittent skilled care

– Physical therapy, speech-language pathology, continuing need for

occupational therapy

– Some home health aide services, medical social services, medical

supplies

• Hospice Care

– For terminally ill and includes drugs,

medical care, and support services from

a Medicare-approved hospice

• Blood

– Received during inpatient care

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Part A Cost Sharing

• Inpatient Hospitalization

– Deductible for 2012: $1,156 (first 60 days)

– Day 61-90: $289/day

– After 90 days using lifetime reserve days (60 days):

$578/day

– After lifetime reserve days are used: No Coverage

• Skilled Nursing Facility

– First 20 days: No cost sharing

– Day 21-100: $144.50/day

– After 100 days: No Coverage

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Part A Cost Sharing • Home Health Care

– $0 for Skilled HHC Services

– 20% for Durable Medical Equipment (DME)

• Hospice Care

– 5% for inpatient respite care

– Room and board, in some cases

– $5 for prescription drugs

• Blood

– 100% first 3 pints

– 20% for additional pints

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Monthly Part B Premium

Yearly Income in 2010 You Pay

File Individual Tax Return File Joint Tax Return

$85,000 or below $170,000 or below $99.90

$85,001 - $107,000 $170,001 - $214,000 $139.90

$107,001 - $160,000 $214,001 - $320,000 $199.80

$160,001 - $214,000 $320,001 - $428,000 $259.70

Above $214,000 Above $428,000 $319.70

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Paying the Part B Premium

• Deducted monthly from

– Social Security

– Railroad Retirement Benefit

– Federal retirement payments

• If not deducted

– Billed every 3 months

– Medicare Easy Pay to deduct from bank account

• Contact SSA, RRB, or OPM about premiums

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Part B Late Enrollment Penalty

• Penalty for not signing up when first eligible

– 10% more for each 12-month period

– May have penalty as long as you have Part B

• Sign up during a Special Enrollment Period (SEP)

– Usually no penalty

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Part B & Employer or Union Coverage

• May affect your Part B enrollment rights

– You may want to delay enrolling in Part B if:

• You have employer or union coverage and

• You or your spouse, or family member if you are disabled, is still

working

• See how your insurance works with Medicare

– Contact your employer/union benefits administrator

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When Employer/Union Coverage Ends

• When your employment ends

– You may get a chance to elect COBRA

– You may get a Special Enrollment Period

• Sign up for Part B without

a 10% penalty

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Paying for Part B Services

• In Original Medicare you pay

– Yearly deductible of $140 in 2012

– 20% coinsurance for most services

• Some programs may help pay these costs

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Medicare Part B Coverage • Doctors’ Services

– Medically necessary services (includes outpatient and some doctor

services you receive when an inpatient) or covered preventive services

– Except for certain preventive services, you pay 20% of the Medicare-

approved amount (if the doctor accepts assignment) and the Part B

deductible applies

• Outpatient Medical & Surgical Services and Supplies

– For approved procedures (like X-rays, a cast, or stitches)

– You pay 20% of the Medicare-approved amount for the doctor’s

services (if the doctor accepts assignment)

– You also pay a copayment for each service and the Part B deductible

applies

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Medicare Part B Coverage • Home Health Care Services

– Medically necessary part-time or intermittent skilled nursing care,

physical therapy, speech-language pathology services, occupational

therapy

– Medically necessary part-time or intermittent home health aide

services, medical social services, and medical supplies

– Durable medical equipment and an osteoporosis drug are also covered

– You pay nothing for covered services

• Durable Medical Equipment

– Items such as oxygen, equipment and supplies, wheelchairs, walkers,

and hospital beds for you in the home. Some items must be rented.

– You pay 20% of the Medicare-approved amount and Part B deductible

applies

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Medicare Part B Coverage

• Other Services (including but not limited to)

– Medically necessary medical services and supplies, such

as:

• Clinical laboratory services

• Diabetes supplies

• Kidney dialysis services and supplies

• Mental health care

• Limited outpatient prescription drugs

• Diagnostic X-rays, MRIs, CT scans,

and EKGs

• Transplants

– Costs vary

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Part B Covered Preventive Services • One-time “Welcome to Medicare” physical exam

• Annual wellness visit after 12 mos. enrolled in Part B

• Immunizations – pneumococcal, hepatitis B, annual flu shot, H1N1

• Abdominal aortic aneurysm screening – one time, with referral

• Bone mass measurement – every 24 months for certain conditions

• Cardiovascular screening blood tests – every five years for all persons

• Colorectal cancer screening – four different tests, vary in frequency

• Diabetes screenings – up to two per year for those with risk factors

• EKG screening – one time, with referral

• Glaucoma testing – once per year for those at high risk

• HIV screening

• Mammogram – annual screening for most women

• Pap test and pelvic exam – every 24 months

• Prostate cancer screening – every 12 months for men over age 50

• Smoking cessation counseling

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NOT Covered by Part A and Part B • Acupuncture

• Dental care/dentures

• Cosmetic surgery

• Custodial care

• Health care while traveling outside

the U.S.

• Hearing aids

• Orthopedic shoes

• Outpatient prescription drugs (covered under Part D)

• Routine foot care

• Routine eye care and eyeglasses

• Vaccines, except as previous listed (covered under Part D)

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What is Original Medicare?

• Health care option run by the Federal government

• Provides Part A and/or Part B coverage

• See any doctor that accepts Medicare

• Beneficiary pays:

– Part B premium (Part A free for most people)

– Deductibles, coinsurance or copayments

• Can join a Part D plan to add drug coverage

• Can join a Medigap plan to pick up the “gaps”

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Assignment

• Doctor, provider, or supplier accepts assignment – Signed an agreement with Medicare

– Or is required by law

– Accept the Medicare-approved

amount

• As full payment for covered

services

• Only charge Medicare

deductible/coinsurance amount

• Most accept assignment – They submit your claim to Medicare directly

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Supplier and Assignment

• Suppliers that don’t accept assignment

– May charge you more

• The limiting charge is

15% more

• May have to pay entire

charge at time of service

• Providers sometimes must accept assignment

– Medicare Part B-covered prescription drugs

– Ambulance suppliers

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Medicaid

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Medicaid

• Federal-state health insurance

program

– For people with limited income

and resources

– Certain people with disabilities

• Most costs covered for Medicare/Medicaid

– Called “dual eligible”

• Eligibility determined by state

• Application process and benefits vary

• Office names vary 33

Medicare Savings Programs

• Help from Medicaid paying Medicare costs

– For people with limited income and resources

– Programs include

• Qualified Medicare Beneficiary (QMB)

• Specified Low-Income Medicare Beneficiary (SLMB)

• Qualifying Individual (QI)

• Qualified Disabled & Working

Individuals (QDWI)

• See state websites for more

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Medicare Resources

Resources

Centers for Medicare & Medicaid Services

(CMS)

1-800-MEDICARE

(1-800-633-4227)

(TTY 1-877-486-2048)

www.medicare.gov

www.CMS.gov

Social Security 1-800-772-1213

(TTY 1-800-325-0778)

www.socialsecurity.gov

Railroad Retirement Board 1-877-772-5772

www.rrb.gov

State Health Insurance Assistance

Programs (SHIPs)*

*For telephone numbers call CMS

www.medicare.gov

Affordable Care Act www.healthcare.gov/center/authorities/pat

ient_protection_affordable_care_act_as_p

assed.pdf

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Upcoming Webinar

• Medicare Advantage

– September 6th 12:00pm CST

*Annual Election Period (AEP) is October 15th –

December 7th

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Questions?

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